Badge Request Form

New (First Badge at Salem Health) or Replacement?*

Badge Requested For*

Name of Requester*

First NameLast Name

Legal Name for Badge*

First NameLast Name

Preferred Name for Badge (if different from legal)

First NameLast Name

Select preferred pronouns (optional)

Employee or Non-Employee Number for Badge (If you are new to Salem Health and do not know your employee/non-employee number, please skip this field)

Badge Wearer Email Address*

example@example.com

Phone Number

Area CodePhone Number

Name of Salem Health's contact (needed for contractor badge) - Approving person.*

Start Date*

Date

Date Badge is Needed*

Date

Name of School*

Field of Study*

Start of Assignment*

Date

End of Assignment*

Date

Company Name*

Job Title*

Badge Replacement Reason*

Preferred Name for Badge (if different from legal)

First NameLast Name

Select preferred pronouns

Are there credentials that should be added to this badge (ex. JANE DOE, BSN)?*

YesNo

Please type all credentials below as they should appear on the badge:*

Please upload supporting documentation for all credentials appearing on the badge:*

Browse Files

Please select how you would like your name to appear on your badge:*

"First, Last""First, Last" on side 1 and and "First" only on side 2

Job Title*

Department*

Work Location*

Photo Guildelines:

Before your first day of work you will need to submit a photo for your hospital I.D. badge. We want you to be happy with the picture on your badge and we want it to send a positive and professional message to our patients and your fellow employees. If the badge photo that is submitted does not meet the below standards there may be a delay in getting you an ID badge. The guidelines and examples below will help you get a “picture perfect” badge photo;

Please upload a photo for your badge (IMPORTANT! Please ensure that your file name DOES NOT INCLUDE any of the following characters: . ? # @)*

Browse Files

Please describe the desired change(s) below *

Ex. Name change: From Smith to Jones; Position change: CNA in NTCU to RN in Adult Health

Non-employees will need to pay the $10 fee (cash only) for badge replacements prior to receiving their new badge.

Method of Payment*

I hereby authorize my employer (Salem Health or West Valley Hospital) to deduct from my pay $10.00 for employee badge replacement at Salem Health or West Valley Hospital using my employee identification badge. All purchases made during a pay period will be combined and deducted from my pay for that period. I understand that the hospital may establish limits on the amount that may be purchased through payroll deduction at any single location and/or in the aggregate for all locations. I understand that this authorization will remain in effect until I withdraw it in writing, change status to no longer be a regularly scheduled full-time or part-time employee,or terminate my employment with Salem Health or West Valley Hospital. I also understand that in the event I resign or for any other reason cease to be employed by Salem Health, the full amount of such authorized deduction will be deducted from my final paycheck. In the unlikely event that my final pay check is insufficient to repay the total unpaid amount in full, I will be responsible for repaying the balance directly to the hospital. *

Date*

Date

IDENTIFICATION BADGE CARE AND RESPONSIBILITY STATEMENT

The hospital strongly encourages the use of first and last name on the Hospital Identification badge, and this is a requirement for management, supervisory, and security staff. Your first and last name will be automatically printed on your ID badge unless you specifically request the option of having your first name and last name initial only.

This identification badge is intended to provide a secure environment and identify our employees to our patients and visitors. It also provides access to secured areas and the automated time and attendance system.

Your ID badge is used as identification and all staff members are required to wear it picture-side out, visible at all times, and on the upper body while working in the Hospital or Hospital-owned facilities.

The badge also provides access to controlled areas, by holding the badge within 2 to 4 inches of a door control reader.

A microchip and coil is embedded within the card and will be damaged if bent, creased, or punctured with pins (including employee anniversary pins), etc. For this reason, do not put anything on your ID badge including stickers other than the green dot or additions specifically approved by administration.

A fee of $10 will be charged for badges that are lost, stolen, or damaged beyond reasonable wear and aging. If a new badge is needed due to normal wear and/or aging, the new badge will be issued at no cost. Once you have replaced your badge, the old one will no longer work; access will be deactivated. Old badges must be turned into Security if found or replaced.

If you forget your badge, you must return home to retrieve it before working your shift. If you cannot return home, you must purchase a replacement badge at the $10 cost before working your shift. Old badges must be turned into Security if found or replaced.

There will be no charge for title, names changes, or if adding any degrees (the old badge must be returned). Only one badge should be in your possession at any time.

The ID badge is used in patient care areas for safe medication administration.

It is your responsibility to care for and protect this badge from loss or damage. Security breaches can occur if the badge is found and used by someone other than an employee.

You must report lost badges to Security immediately, so they can remove access from your identification badge.

Any lost badge located after being replaced or any badge no longer in use must be returned to Security.

I understand the above requirements and the cost of replacement for lost or damaged cards. I have received the Fast Track Safety Orientation.

I understand the above requirements and the cost of replacement for lost or damaged cards. I have read the Identification Badge Care and Responsibility Statement above. *

Date*

Date